Experienced LPNs give a newbie LPN some tips!

kstec, LPN · Jan 19, 2008

First and foremost the staff/patient ratio sounds good. I would also be surprised if you get more than a week of training. Most LTC facility are short staffed and will push you on your own quick. When I come in to work, I get report, trigger in on the diabetics who have accuchecks, residents with present behavior problems, S&S of infection, fever or adverse reaction to the residents on antibiotics. After you've gotten report, do a quick look at all your residents just to get a feel of what their appearance is and do they look pale, sick, or just plain not right, then do blood sugars, administer insulin as directed. They say not to check blood sugars in the halls or dining room and also with giving insulin. I do, why because as much as I would love to run each diabetic to a private area after hunting them down, it just isn't going to happen. Be discreet as not to offend other residents or family members. Always flag your diabetics as priority, if you have Medicare residents they usually have to be charted on per medicare standards each shift.

Try and do a quick head to toe assessment with vitals and document. Other residents you hope and pray the CNA's will tell you that they have a reddened area wherever it may be. Ask them, did they see anything, but if they are good CNA's they will report anything abnormal to you, even if it has already been addressed last shift or yesterday, then go look at it and document on appearance and to wound care tx. or apply a barrier cream if the CNA hasn't. If they are on a ABX for a upper respiratory infection, check lung sounds, get vitals. If they have a UTI observe for a temperature, or weird mental behavior also ask the CNA if they noticed an odor or dark color of the urine. The weird behavior even if they were weird before will be more intense if they have a UTI. Always chart by exception on anything you observe, it covers your butt. Always fill out incident reports, call the MD, call the family and monitor the patient as much as possible for anything abnormal. If you notice a resident is coughing always listen to lungs for crackles. The geriatric population are most prone to URI's, UTI's and injuries of some sort. It may even be they scratched their hand on the door frame while pushing themselves through the door, measure it, document it, call the MD, call the family, fill out an incident report and pass it on to the next shift. It's seems like alot of information, but just learn alot of it as second nature and always have your eyes and ears open. Assessment skills if number uno in LTC. The med pass is a large part, but your less likely to make a med error than you are to miss something small with a resident which will then turn around and bite you in the butt.

You'll be a nervous wreck at first, then if you can make it until you get to know each residents quirks, and behaviors, you've got it made in the shade. You will then be their best advocate and be able notice anything abnormal. Always use your eyes and ears and follow protocol and you'll do fine. And also if you put your heart and soul into taking care of your residents the big boy upstairs somehow makes it so you don't make mistakes or if you do there minor and not nearly as bad as the nurse whose in the job just for a paycheck. She will hurt someone, someday. Sorry this is long, but as a fairly new grad (1 1/2yrs) I just wanted to share with you what my experience has shown me. Any other questions, feel free to ask. And of course someone on this website will dispute some if not all of what I said, but that is just part of this website.

BayouLPN · Jan 22, 2008

I totally agree with kstec. A week of orientation will be a miracle. The advice she gave is spot on. You will learn to get your meds out quickly...you will learn what shortcuts you can safely take. You will learn assessment skills. My biggest time to get organized is on my way to work. I drive 35 minutes there. I get in the car and begin to think about my day. I plan what I want to accomplish and how to go about it. If something comes up...I have to rearrange some but since already had my gameplan in my head, it is no big deal. My game plan is the same most days...it just helps to think about it before going in. Get report, draw insulins, do accuchecks & give said insulins...sometimes s/s is needed. put away accucheck equipment, get cart & hit floor. Ideally try to get people coming down the hall to the dining room. If I can hit them going in or while they are eating....GOOD DAY. Then I start halls...bedbound, ones in the showers, ect. While passing meds I look over my people...for walky-talky's...I asked questions...How are you today? Feelin ok? That old cough still bothering you?, You still drinking cranberry juice like I told you? I cover alot of ground in those first 3-4 hours of work when to the bystander it would look like I am randomly popping pills and having social hour. If you are in the facility long enough...you will be able to see when one of your "people" are getting sick. Medicare is much more strenous charting...full head to toe. I catch after lunch usually unless they have something acute going on. Chart by exception and for ABX, fevers, unusual behavior. Starting on the 3-11 shift is going to be better in my opinion because these little old folks like to be in bed by 7pm and it is much more quiet than earlier in day. In the beginning take your time, watch your preceptor, and then develop your own routine. You mainly need training for paperwork, when & why & how to call a md, what to do in an emergency, ect. Most other nurses in the facility won't mind answering questions and helping. I have personally only had one that I overheard talking on the phone about having to "help the newbie along" and even then she went out of her way to help me. Good Luck with your new job

LPNAngel · Jan 22, 2008

Starting on 3-11 shift, should be easier then days for you. I must say before I put in my :twocents: worth I have not worked in nursing since 2001 so laws & some things do change, but the basic's doesn't. Prior to 2001 I worked as an LPN since I graduated in 1981, all in skilled LTC. The longest I worked in one place was 13 years. I will tell you the basic schedule I worked out for myself, (around the facilities normal schedule) & it worked out great.

The facility I worked at had 180 patients, 60 patients to each of 3 wings. Each wing on 3-11 had 1-LPN & 6 CNA's, we only had an on call RN evenings & nights. Each LPN was responsible for 60 patients. Each CNA was responsible for 10 patients. We had all kinds of VA, Medicare, Medicaid so they could not keep the patient load prefectly even as the Medicaid ones had their own little section with specified beds, Alzheimer's had their section etc. On an average we would have 4 or 5 tube feeders, 10% or so complete bed care.

Even though we always worked the same wing, (except the floaters), we were required to have report at shift change as a whole so we were familier with the names & problems of patients on other wings. If one nurse was running behind due to an accident, death or something we all pitched in & helped each other & we needed a general idea of what might be happening on each others floor. We also did not have med tech for med passing so the LPN passed meds also in 1981.

2:45 to 3:15 shift change report for nurses. Day & evening CNA's were doing rounds together. 3:15 we started 4 PM meds & did our first med pass with our first rounds to see each patient. Had to get those sugars done & insulin's out by 4:30 also as evening meal was at 5 PM. If we were not done with meds yet (we never were), the med cart got put up, sugars & insulin's done, then we started meds again & finished. This was one place where the privacy thing they teach you about everything being done in private was not always done. They were not so picky then, but the residents didn't seem to mind if they were already in the DR ready for supper. This is a time when the nurses attitude & professionalism comes into play. Be a patients friend, talk to them, make them feel special, pull up a sleeve do what you gotta do & don't make a big presentation about it when you have to do small things in public & it will never go noticed as it is normal in a LTC facility.

5 PM aides are passing trays & feeding their residents who need fed. We are cleaning up med cart, putting things away. Getting our skin treatment cart ready. Do some charting now if you have time. Somewhere in here you eat supper yourself. OH yeh at 6 we started our tube feedings & even if we had a lot we were don by 6:45 for our supper. After our supper, it was time to start putting them to bed. As the aides were putting their residents to bed we worked together & did skin treatments at the same time. Starting at 7:30 it was time to start 8 PM meds which were done by about 9 PM. We gave the bedtime snack with med time so we could talk to every resident again & make rounds sort of say again so we took our time. After 9 PM, had to finish any treatments we didn't get done before meds. Finish charting to current times. 10 PM time to give aides a hand if they needed help with something, give the sick residents a good checkin while the aides are doing last rounds for shift change & do 10 PM tube feedings.

This was out basic schedule, of course, you have the emergencies, doctor to call, falls, sick patients requiring more care, IV's, breathing treatments, diabetic foot care, (we did this on evenings) & other misc stuff I have since forgot, but we got things done.

I worked in 3 different places & the one I remember the best was also the longest, great team members. They gave great care also, I felt comfortable enough there I had grandma's, grandpa's, aunts, uncles all as patients there. It was a very nice LTC facility & most of it was the relaxed enviroment, we did things by the book also. One place I worked for 3 months & finally gave up & had to quit......... had no organization at all, just a complete wreck so getting organized in a schedule is a must. Biggest must haves are big pockets & they little notebook in your pocket to write down EVERYTHING as you do not have a patients chart with you at all times for things you have to chart. When you do your charting you can easily get out your notebook & it is all there for you.

In your spare time, (LOL I know spare time). Read each patients chart, meds, diagnosis, previous nurse notes, visit with residents & really get to know them, it sure saves time later. You need to know them like the back of your hand. After all these years I could still tell you names, diagnosis, who hated a bath, who was a fighter, biter, or the little quirks about each of them, the meds they were on, how high they liked their bed elevated, where their pillows went.

Good luck, you will do fine, if you weren't a caring person you wouldn't be a nurse.

Lovely_RN, MSN · Jan 25, 2008

First day of orientation went well but I suppose that is because I wasn't actually on the floor

Aye caramba, all of that paperwork, how will I ever manage?

I am on 3-11pm and I have to do all of this: Count my narcs, get report, do rounds, make assignments, fingersticks + insulin before 5pm because that is when dinner starts, and start the tube feeds. In the middle of all of that I am supposed to have a break at 4:15pm because taking one at 6:15pm would mean I am in the middle of my med pass.

Mind you if I get an admit then I gotta deal with that and also the family members usually pop up around this time too.

Um excuse me ya'll but how in the HECK am I supposed to get ALL of this done before 5pm?

After 6pm med pass I should be able to squeeze in dinner but I gotta get those treatments done and then do a little charting on episodic patients. I need to pray that no one will fall, escape, or die on my shift because that will throw a monkey wrench into everything. Then there is the 10pm med pass and after that I should be giving report and then I am free to go.

The lovely lady who is doing my orientation (she is actually very nice) gave me a heads up about the CNAs on my floor. Basically 2 of them are "lifers" meaning they have been at that facility for 20+ years and they are known for giving people a hard time (union job) so I need to be tough but at the same time build a relationship with them but at the same time don't get to friendly least they walk all over me. She also tells me that it doesn't help that I am baby faced and look like a I am in my early 20s even though I am over 30 myself.

I went up to the floor to introduce myself and they just looked, for a lack of a better word, p*ssed off at my existence.

Wow, seems like I am really going to get a chance to put my people skills to work. I'm a bit of a dictator, with a bit of control freak thrown in too boot. In past jobs I would cover it up by bringing in my subordinates a box of cookies and making nice with them while at the same time telling them what to do all along. I plan to go this route with those CNAs. Do you think I stand a chance in heck?

Well, I guess this is the part where I get to see what I am really made out of. :pumpiron:

LPNAngel · Jan 25, 2008

First day of orientation went well but I suppose that is because I wasn't actually on the floor
Aye caramba, all of that paperwork, how will I ever manage?
I am on 3-11pm and I have to do all of this: Count my narcs, get report, do rounds, make assignments, fingersticks + insulin before 5pm because that is when dinner starts, and start the tube feeds. In the middle of all of that I am supposed to have a break at 4:15pm because taking one at 6:15pm would mean I am in the middle of my med pass.
Mind you if I get an admit then I gotta deal with that and also the family members usually pop up around this time too.
Um excuse me ya'll but how in the HECK am I supposed to get ALL of this done before 5pm?
After 6pm med pass I should be able to squeeze in dinner but I gotta get those treatments done and then do a little charting on episodic patients. I need to pray that no one will fall, escape, or die on my shift because that will throw a monkey wrench into everything. Then there is the 10pm med pass and after that I should be giving report and then I am free to go.
The lovely lady who is doing my orientation (she is actually very nice) gave me a heads up about the CNAs on my floor. Basically 2 of them are "lifers" meaning they have been at that facility for 20+ years and they are known for giving people a hard time (union job) so I need to be tough but at the same time build a relationship with them but at the same time don't get to friendly least they walk all over me. She also tells me that it doesn't help that I am baby faced and look like a I am in my early 20s even though I am over 30 myself.
I went up to the floor to introduce myself and they just looked, for a lack of a better word, p*ssed off at my existence.
Wow, seems like I am really going to get a chance to put my people skills to work. I'm a bit of a dictator, with a bit of control freak thrown in too boot. In past jobs I would cover it up by bringing in my subordinates a box of cookies and making nice with them while at the same time telling them what to do all along. I plan to go this route with those CNAs. Do you think I stand a chance in heck?
Well, I guess this is the part where I get to see what I am really made out of. :pumpiron:

You will do fine, each facility has a different schedule, your meds are at 6 & 10, ours were at 4 & 8. When you train with a nurse on the same floor, she will show you the basic schedule she uses & you can tweak it to fit you, to get in a routein of your own.

The "lifers" CNA's, yes you need to watch these. We had a few where I worked at, but they were there so long for a good reason, they did a great job, (at least these did). They were picky, they would rat you out if necessary & yes they had been there SO long, they really did know more then a new person to start as far as "knowing the patients". They knew their habits, likes, dislikes, actions, diagnosis. Knowing these things can be critical sometimes, but also it can make your job so much easier as they are valuable because they will notice any slight change faster than someone else might, they have seen these residents for years & can spot if something is wrong that day, tjat is ever so slight, a new person doesn't notice it. They have experience & are usually reliable, if you ask them to take vitals, you can trust they are accurate, these kind of CNA's sometimes can help you the most because of this also. I like you had the glare from them for a while being I was a newbie & their supervisor, but they had senority. I remained very professional when it was time to "work", let them know I expected nothing less that excellent patient care with dignity. We were friends, worked as a team, give constructive criticism if necessary. Do not, repeat do not, let them walk all over you, if it happens once, then they know they got ya.

Yes, you have a good chance, cookies, snacks etc. once in a while is a good idea. Once they see you are professional & do a good job, they will respect you.

Good luck,

Teresa

:up:

BayouLPN · Jan 27, 2008

Just remember...there is the "schedule" and then there is "The Schedule". One you will try to go by...one is the real world. Life doesn't revolve around what a business says you must have done by this exact time. And dementiated and or sick patients sure don't live by that rule. Hang in there...it will come. As for your lifers. and mine. I never brought them anything. Couldn't afford to in the beginning. But...I did make nice. When they told me something, I listened. When they asked for help, I helped. Most lifers will not ask...I would just jump in. When they thought they were going walk over me bye-bye nice. I had one who decided she wasn't doing VS because she worked short that day. Didn't tell me she "was not going to do them" until her shift was almost over. Very hateful. My reply was...When have I ever seen you done wrong? Why didn't you come tell me you were having a hard time getting to them. You know, I would have pulled someone else or done them myself. This just makes you look bad when I have to report you to the DON and you know da#@ well that I don't want you wrote up." At the end of our conversation, she got VS with help from another aide. She hasn't tried that with me since...she has asked for help, though.

Lovely_RN, MSN · Jan 30, 2008

Orientation is going Ok, nothing more than that. So far i'm feeling like eh it's alright but it sure ain't nothing to write home about.

A few things that are annoying me.

First example: I'm learning how to do med pass and my two experiences so far have sucked. Yesterday I get to follow around this one nurse who barely lets me look over her shoulder at what she is doing. That was annoying but I managed to glean enough information to get the picture.

I know that everyone isn't a natural teacher but I got tired of having to say: Ok, what are you doing now? Ok, so you do that because? How do you follow up? How do you document? What if this situation occurs? It's annoying because I don't really know if there are questions that I am not asking and they are not being forthcoming with information.

Day 2 of doing med pass with another nurse (same unit). The DNS told that I need to do a med pass on my own and I give this information to the RN. She will not let me do the med pass instead she gives me a 2 minute explanation about doing things the right way for the state followed by doing everything the exact opposite of how we are taught to do it. Ok, I understand that we can't do everything by the book in RL because we would never be done but trust me you had to be there to believe it.

She was just yanking things out of the cart, crushing them, and throwing them into cups before handing it to me; w/o glancing at the MAR in some cases. I'm not cool with this at all because I need to SEE what is being done step by step. I want to pull my own drugs and look at them before administering them. Ok, fine this is her unit and she is used to the residents but the not looking at the MAR thing unnerves me. She gets a tiny bit huffy because I will not sign for anything she takes out and when I get my turn she is hustling me because she doesn't want to be late for break.

I understand that to her this is all routine but to me it isn't. Right now I am on a vent unit and we have one patient out of the whole lot who can take meds PO. The rest get it through their GTs so it can take a long time to do med pass if you are not quick. Even with having to administer meds via GT to 18 pts we are finished in 2hours and since she gave out half the 2pm meds at 10am when we came back from lunch we really had very little to do. This annoys me because she isn't rushing me because we will not finish she is rushing me so that we can sit on our butts yawning from 1:30-3pm if she has it her way. So we are sitting there and I am prodding her with my usual 100 questions. She looks pained until the DNS calls and asks her about what she is teaching me then she decides to actually do something and teaches me about picking up orders and other paper work.

Well lets see what happens for the rest of the week.

On a good note because I don't want to just complain about what is going wrong. The RT is really cool and I got an excellent hands on experience with trach care and suctioning. I basically spent the entire day with RT on Friday and by the end of the day I could do suctioning and trach care like I was born doing it. I guess some people are just better teachers than others.

BayouLPN · Feb 1, 2008

Hang in there. Alot of people are not good teachers. Alot of LTC nurses are overworked and understaffed. Tired of training people then watching them walk out the door. They develop very hard, sour attitudes. I would guess your preceptors didn't do much assessing or communication with residents, either. Which leaves them not very good nurses or just plain burnt out. Which may be why you were hired in the first place. Keep your pleasant attitude. Watch what she does...you are going to do your own thing when you start on your own, anyway. Don't sign NOTHING you are not comfortable signing if not done by you. And if things get too bad...Go to your DON (DNS?) and explain the situation to her. Don't whine, just state that you feel overwhelmed by this nurse who is not very forthcoming with explanations or advise. And you would like her opinion on how best to improve the situation. GOOD LUCK

HeartJulz · Feb 2, 2008

Out of curioosity? where did you do your clinical rounds? I did mine at a SNF/LTC for 10 mths 12+ hours a week sat & Sun. It was GRUELING! But they shoudl have taught you the just of what you would be doing in clinicals. I knew about getting report along w rounds and counting narcs... fingersticks and insulin before lunch and also making sure you turn on or off the TPNs and also I learned a lot when it came to the tube feedings. All the paperwork, charting, faxing, catheters, TBs ( that was in our down time), pulse oxs, checking O2 machines.. etc etc etc... we were always assigned a nurse and it became that we would eventually do it and then the nurse watched over us. I am SOOO lucky the facility I was at most the nurses were friendly and watnted to help.. heck even one of them was at our grad who helped 'pin' us.. I really want to apply there after I pass nCLEX... so after I read most this thread I wondered where they put you at when U did clinicals in school?

Lovely_RN, MSN · Feb 3, 2008

I had one 4 week rotation at a LTC and I was not on a skilled nursing floor like the one I am on now. There were some total cares but most of the patients were walkie talkies and we didn't stay for an entire shift. The rest of our clinicals were in the hospital. Basically, looking back on it clinicals were a joke and did not prepare me at all for working as an LPN in a LTC. The nurse's were busy and beyond unfriendly so no help there. My stupid school focused on being able to work in a hospital (when most of the hospitals in my area employ very few LPNs) We really did the work of CNAs in our nursing home rotation.

Luckily I am a pretty fast learner and I am getting a relatively long orientation so things aren't going badly at all.

Out of curioosity? where did you do your clinical rounds? I did mine at a SNF/LTC for 10 mths 12+ hours a week sat & Sun. It was GRUELING! But they shoudl have taught you the just of what you would be doing in clinicals. I knew about getting report along w rounds and counting narcs... fingersticks and insulin before lunch and also making sure you turn on or off the TPNs and also I learned a lot when it came to the tube feedings. All the paperwork, charting, faxing, catheters, TBs ( that was in our down time), pulse oxs, checking O2 machines.. etc etc etc... we were always assigned a nurse and it became that we would eventually do it and then the nurse watched over us. I am SOOO lucky the facility I was at most the nurses were friendly and watnted to help.. heck even one of them was at our grad who helped 'pin' us.. I really want to apply there after I pass nCLEX... so after I read most this thread I wondered where they put you at when U did clinicals in school?

Lovely_RN, MSN · Feb 3, 2008

Thanks Bayou,

Yes, this place does run through a lot of people so I guess the nurses probably think I will likely leave soon too. The thing is that if they gave people a half way decent orientation maybe they wouldn't be overwhelmed and quit as soon as they finish the orientation.

I'm sticking it out because next week I am going to a different floor to train with another nurse. I am going to keep a wait and see type attitude about this place. I just don't like the attitudes that I had to deal with last week.

The nurses were kind of making fun of me for being overly cautious. Well I don't care if they want to laugh at me and I don't think that I'm overly cautious.

I refused to count narcotics one day because the night shift nurse didn't give me the keys and she had already left. I'm not going to count if the night nurse is already gone. I know she is friends with the day shift nurse and maybe they have that level of trust but I don't know them from a hole in the wall and I'm not taking any chances. Truly, I wouldn't do that for my own mother.

I also didn't want to count because they toss those keys around like it's nothing. They will leave them in open view on the desk and walk away. I don't want to be responsible for the narcs when I can't hold onto the keys at all times.

Another incident, I signed out for a Fentanyl patch and asked the nurse to witness it and she just waved her hand at me. I then asked her to witness me wasting the old patch and again she was like whatever. When I drew up insulin I asked her to look at the syringe to double check and she was like "oh, you don't have to do that"

I was given a skills check off list by the DNS and another nurse just signed off on everything and I was like "Hey, don't you have to at least watch me do these skills?" Again the attitude is nonchalance.

You are also accurate in your guess that very little time is spent with the patients or on doing assessments. There is more but I don't want to provide too much information for fear of being identified. I think that patient care may be compromised but I am not sure if my judgment is off because of my lack of experience.

Hang in there. Alot of people are not good teachers. Alot of LTC nurses are overworked and understaffed. Tired of training people then watching them walk out the door. They develop very hard, sour attitudes. I would guess your preceptors didn't do much assessing or communication with residents, either. Which leaves them not very good nurses or just plain burnt out. Which may be why you were hired in the first place. Keep your pleasant attitude. Watch what she does...you are going to do your own thing when you start on your own, anyway. Don't sign NOTHING you are not comfortable signing if not done by you. And if things get too bad...Go to your DON (DNS?) and explain the situation to her. Don't whine, just state that you feel overwhelmed by this nurse who is not very forthcoming with explanations or advise. And you would like her opinion on how best to improve the situation. GOOD LUCK